MPOG Pediatric
Subcommittee Meeting
May 19, 2021
Agenda
5 minutes
Announcements
10 minutes
PONV/Antiemetic Data Review
20 minutes
Transfusion Vigilance (TRAN-01)
Measure Review and Discussion
20 minutes
Overtransfusion (TRAN-02)
Measure Review and Discussion
2021 MPOG Meetings
• Pediatric Subcommittee Meetings
- August 18
- October 9 (TBD: Virtual vs. In person)
- December 15
• MPOG Annual Retreat 2021
- October 8 (San Diego, CA)
February Meeting Recap
Measure Discussion
PONV Prophylaxis in Pediatrics
PONV-02 Inclusion/Exclusion Criteria
OLD (2018)
Inclusion
• Patients ages 3-17 years old
• Received an inhalational general anesthetic
• Has ≥ 2 risk factors for POV
Exclusion
• Patients < 3 or > 17 years old.
• Patients transferred directly → ICU
• Liver or Lung Transplants
• Procedures on the Neck
• Intrathoracic Procedures
• Procedures on the Lower Abdomen
• Obstetric Procedures & Labor Epidurals
• Endoscopy
• Obturator neurectomy
• Shoulder cast application
UPDATE (2021)
Inclusion
• Patients ages 3-17 years old
Exclusion
• Patients < 3 or > 17 years old.
• Patients transferred directly → ICU
• ASA 5 or 6
• Labor Epidural cases
• Diagnostic Imaging Procedures
Gan et al, 2020
PONV-02 Risk Factors
OLD (2018)
• Hx of PONV
– personal or first-degree relative
• At Risk Surgery
– Strabismus
• Procedure ≥ 30 minutes
UPDATE (2021)
• Post-pubertal females (≥ 12y)
• Inhaled anesthetic duration ≥ 30 minutes
– halogenated and/or nitrous oxide
• Hx of PONV
– personal or first-degree relative
• At Risk Surgery
– Strabismus
– Adenotonsillectomy
– Tympanoplasty/Otoplasty
• Postoperative long-acting opioids
– Administered after Induction
Gan et al, 2020
PONV-02 Success Criteria
OLD (2018)
Patient receives at least two prophylactic
pharmacologic antiemetic agents of
different classes preoperatively or
intraoperatively
UPDATE (2021)
Low (0 risk factors)
• Patient receives at least one prophylactic pharmacologic
antiemetic.
Medium (1-2 risk factors)
• Patient receive combination therapy consisting of at least
two prophylactic pharmacologic antiemetics from different
classes.
High (>2 risk factors)
• Patient receives three prophylactic pharmacologic
antiemetics.
Gan et al, 2020
Choice of Antiemetics and
Frequency
Measure Review
Transfusion Vigilance
TRAN-01
TRAN 01 - Transfusion Vigilance
Description
Percentage of cases with a blood transfusion that have a hemoglobin or
hematocrit value documented prior to transfusion.
• Transfusion is defined as packed red blood cells or whole blood.
• Prior to the first transfusion, a Hgb/Hct of any value should be checked in a time period of 0
to 90 minutes before the transfusion, or the most recent documented Hgb/Hct was < 8/24
within 36 hours before the transfusion.
Responsible Provider
Provider(s) who administered the transfusion
Inclusion/Exclusion Criteria
Current (2018)
Inclusions
• All patients who receive a transfusion between
Anesthesia Start and Anesthesia End.
Exclusions
• Patients < 2 years of age
• ASA 5 & 6
• Patients < 12 years old undergoing a cardiac
procedure
• Massive Transfusion and/or EBL ≥ 2000 ml
• Patients < 12 years old where either transfused PRBC
or EBL was greater than 30cc/kg.
• Burn Debridement cases
• Obstetric Non-Operative Procedures
• C-section cases with an EBL > 1500cc or with a
HR>110, SBP<85, DBP<45, or O2Sat <95%.
• Postpartum hemorrhage cases
Proposed Pediatric Criteria
Inclusions
• All patients who receive a transfusion between Anesthesia
Start and Anesthesia End.
Exclusions
• Patients ≤ 6 months or ≥ 18 years of age
• ASA 5 & 6
• Patients with cyanosis preoperatively AND congenital heart
disease
• Patients with transfused volume or EBL > 40cc/kg.
• Patients on ECMO
• Burn Debridement Cases?
• All Obstetric procedures
Definitions/Considerations
Current (2018)
Massive Transfusion/EBL
• Patients < 12 years old: transfused volume or EBL was ≥
30cc/kg.
1 Unit of Blood
• 350 cc/unit.
Cardiac Procedure
• CPT: 00560, 00561, 00562, 00563, 00567, 00580).
Obstetric Procedures As determined by the MPOG
Obstetric Anesthesia Type
• Labor Epidurals
• Cesarean Delivery w/ massive blood loss
• Postpartum hemorrhage cases (ICD-10 code: O72.0, O72.1,
O72.2, O72.3)
Proposed Pediatric Criteria
Massive Transfusion
• Transfused volume of ≥ 40 cc/kg
1 ‘Unit’ of Blood
• Patients < 12y: transfused volume 15 cc/kg?
Cyanosis and CHD
• Cyanosis: At least two SpO2 readings < 90% (between Preop
start and Patient in Room)
• CHD defined by ICD-9/10 codes
Success Criteria
Current (2018)
Documentation of hgb and/or hct prior to
transfusion
• If the most recent Hgb/Hct drawn before the first
transfusion is ≤ 5/16, a second unit could be
administered without rechecking Hgb/Hct between
units.
• For patients < 12 years old: Pre-transfusion Hgb/Hct
required before the first unit and an additional
recheck after 15cc/kg has been transfused.
• If multiple units are administered, documentation of a
Hgb/Hct value must be present within 90 minutes
before each administration.
• All transfusions administered between
cardiopulmonary bypass start → end will not be
included for determining measure results for the case.
Proposed Update (2021)
Documentation of hgb/hct prior to transfusion
• If the most recent Hgb/Hct drawn before the first transfusion is
≤ 5/16, an additional 15cc/kg could be administered without
rechecking Hgb/Hct between units.
– For patients < 12y?
• If multiple units are administered, documentation of a Hgb/Hct
value must be present within 60 minutes before each
transfusion.
• All transfusions administered between cardiopulmonary
bypass start → end will not be included for determining
measure results for the case.
Overtransfusion
TRAN-02
TRAN 02 - Overtransfusion
Description
Percentage of cases with a post transfusion hemoglobin or hematocrit value
greater than or equal to 10 g/dL or 30%.
• All Hgb/Hct labs resulted between the time of last transfusion and 18 hours after
Anesthesia End are evaluated.
Responsible Provider
Provider(s) who administered the last transfusion
Success Criteria
• Hgb/Hct value documented as ≤ 10/30 within
18 hours after A.End
OR
• If No Hgb/Hct checked within 18 hours of
Anesthesia End, the case will pass…
– Should this be exclusion or flagged criteria
instead?
Summary of Recommendations
• 1 ‘unit’ transfused definition = 15cc/kg
• Massive Transfusion/blood loss: Total transfused volume (or EBL) of
40cc/kg
• Include patients ≥ 6mo.
• Exclusions
– Cardiac bypass cases (and ECMO)
– All obstetric procedures
– Revisit Burn case exclusion
• TRAN 01 Success
– If multiple units are administered, documentation of a Hgb/Hct value must
be present within 90 minutes before each administration.
• TRAN 02 Success
– If No Hb/Ht checked within 18 hours of Anesthesia End, the case should be
flagged for systematic review
Next Steps...
• We will incorporate your feedback and update the transfusion metrics as
needed
• Next Subcommittee meeting: August 18th @ 1p EST
– NMB-01: Train of Four Monitoring
– NMB-02: Reversal administered
Thank you
